GW1-2022-04316_Well Construction - GW1_20220502

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
14.WATER ZONES
FROM TO DESCRWTION
Well Contractor Name � j,
3a�1- y/s 7/22 lGoIt. fL ' e);-44T,� Zm
NC Well Contractor Certification Number 15.OUTER CASING for multi-tax wells OR LINER if a licable
James Darby Well Drilling, LLC FROM TO DIAMETER FT111clams MATERw
Company Name ft.
C 64r i- �D
16.INNER CASING OR TUBING 'eothermal closed-loo
13677
2.Well Construction Permit#: FROM T° D1AMEXER Tt�clavFss MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc) ft. ft. 1n.
3.Well Use(check well use): ft in.
17.SCREEN
Water Supply Well:
PP Y FROM TO DIAMETER SLOT SIZE THICIINESS MATERLII.
Agriculttual []MunicipaVPublic 0 ft ft. in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft ft. in.
Industrial/Commercial Residential Water Supply(shared) I&GROUT
I Ti ation FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft Q ft
Monitoring DRecovery It ft
Injection Well: ft. ft
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery Salinity Barrier FROM To MATERIAL EMPLACEMENT METHOD
Aquifer Test [3Storrnwater Drainage ft. ft.
Experimental Technology Subsidence Control ft. ft
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessary)
FROM TO DESCRWnON color,hardness,soil/rock in size,etc.
Geothermal(Heating/Cooling Return) Ot}ier(explain under#21 Remarks)
ej It. d It. .0
4.Date Well(s)Completed: W.5,W, Well ID# 0 ft "L
ft fL R
Sa.Well Location: u
Walter Ratchford U ft ft
Facility/Owner Name Facility M4(if applicable) d fs fvr
4176 Gordon Dr. Gastonia, NC 28056 It. 6
Physical Address,City,and Zip
Gaston -00- 2X 21.REMARKS 7—
County Parcel Identification No.( IN) MAY7
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Certification:
N W lCip V-109
JA
6.Is(are)the well(s)Ox Permanent or Temporary Signat ofC 'fi d on cto Dat
ing this form,1 hereby certi at the well(s)was(were)constructed in accordance
Yes' or 'X
7.Is this a repair to an existing well: Y No with 15A NCAC 02C.0/00 or 15A N AC 02C.0100 Well Construction Standards and that a
If this is a repair,fill out known well construction information and explain the nature of the copy of this record has been provided to the well owner.
repair under 921 remarks section or on the back of this form. 23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well site details or well
construction,only I GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS'
t
9.Total well depth below land surface: 0a (ft-) 24s. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
lfwater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter:6 1 A (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
Rotary above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13s.Yield(gpm) Method of test: Blow 24c. For Water Supply& Infection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: HTH Amount: 61?r completion of well construction to the county health department of the county
where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016